Spending More to Spend Less Unit Costs and Cost-Effectiveness of a Tailored Demand Creation Intervention to Increase Uptake of Voluntary Medical Male Circumcision Hello. I will be presenting on the unit costs and cost effectiveness of a tailored demand creation intervention to increase uptake of voluntary medical male circumcision S. Torres-Rueda, J. Chilongani, F. Terris-Prestholt, H. Mahler, K. Kripke, E. Kuringe, R. Hayes, M. Plotkin, M. Makokha, A. Hellar, C. Schutte, G. Mshana, N. Larke, G. Lija, J. Changalucha, J.M. Grund, H.A. Weiss, M. Wambura International AIDS Conference, Durban, 21 July 2016 Improving health worldwide www.lshtm.ac.uk

Background Male circumcision reduces the risk of female-to-male transmission of HIV Greater epidemiological impact of VMMCs in 20-34 year olds (“older men”) Trial Cluster-randomised controlled trial conducted in Tanzania (Njombe and Tabora regions) Aim: to assess the impact of a tailored demand-creation intervention on VMMC uptake among older men Circumcision has been shown to the reduce the risk of HIV acquisition in men. Modelling studies have found that a greater impact is achieved if VMMC targets 20-34 year olds (which we refer to as older clients). However, the uptake in this group tends to be substantially lower that in other age groups. A randomised controlled trial was conducted in two regions in Tanzania: Njombe and Tabora. The aim of this trial was to assess the impact of a tailored demand-creation strategy on the uptake of VMMC in older men. There were a total of 10 clusters per region, evenly divided between trial arms. This tailored demand creation strategy was informed by formative research in the regions to determine what service attributes men valued the most. In the control arm, standard demand creation and service were delivered. In the intervention they were delivered with additional tailored strategies, including: -Use of peer promoters (circumcised men from the community) -Information sessions for female partners -Separate waiting areas for adults and children -Targeted non-HIV specific messages The trial found that the mean number of VMMC clients of all ages was higher in the intervention arm than in the control. The mean number and proportion of clients 20-34 was higher in the intervention arm. But there were strong regional differences with little effect on uptake in Njombe but over a two-fold difference in Tabora. Results Mean number of VMMC clients of all ages was higher in the intervention arm Mean number and proportion of clients aged 20-34 greater in the intervention arm

Methods Costs Top-down, providers’ perspective Cluster-specific Activities: surgeries, demand creation, monitoring and supervision, start-up (training and formative research) Effects VMMCs per cluster HIV infections averted ART-related savings Decision Makers’ Program Planning Tool (2.1) Assumed a 15 year time frame, ART cost per year $515, 3% discount rate DALYs averted calculated Salomon et al. (2015) disability weights, 70% ART coverage, 3% discount rate For our EE, we collected cost data from the providers perspective from all 20 clusters. We used a top-down methods which accounts for wastage. We collected costs of: -the surgical procedure -the demand creation activities -monitoring and supervision -start up costs (training and formative work) In terms of effects, We collected the total number of men circumcised per cluster from the trial data set. we used the Decision Makers’ Program Planning Tool (2.1) to estimate number of HIV infections averted from VMMCs and cost-savings related to antiretroviral treatment We calculated DALYs averted using a standard method as per Hanson and Foxrushby.

Results: Total and Unit Costs Total costs Unit costs Results We found that total VMMC costs were higher in the intervention arms in both regions. However, when we looked at unit costs, so the cost per VMMC, we found the opposite. Costs per circumcision were lower in the intervention arms across both regions, than in control arms. Unit costs were also generally higher in Njombe than in Tabora. These differences in unit costs are due to the differences in the number of men who were circumcised in each arm. Total number of VMMCs higher in the intervention arms. In the intervention arm in Njombe, 1797 men were circumcised, compared to 1025 in the control. Similar trend in tabora Total costs were higher in the intervention arms in both regions… …but unit costs ($ per VMMC) were lower in the intervention arms

Results: Unit Costs Provider Cost (USD) per VMMC per Cluster In fact when we look at the unit costs per VMMC across all 20 clusters we see that as the number of men circumcised increase, the unit costs decrease and we get this nice downward curve. This leads us to think that economies of scale were observed in the delivery of VMMC. Provider Cost (USD) per VMMC per Cluster

HIV infections averted Results: Effects HIV infections averted DALYs averted We then looked at the effects that stemmed from performing all those circumcisions. We found two interesting things. The first is that the number of infections averted was higher in the intervention arms in both regions. As you can see, in Njombe 164 infections were averted in the intervention arm v. 102 in the control arm. Same trend in Tabora. The second thing we found was that generally more infections were averted in Njombe than in Tabora, despite the fact that more circumcisions were performed in the Tabora . We suspect this may be due to the higher HIV prevalence in Njombe. When we look at DALYs averted, we see a similar trend, with greater number of DALYs averted in the intervention arms in both regions; and greater number of DALYs averted in Njombe than in Tabora. Differences due to higher HIV prevalence in Njombe

Results: Cost-Effectiveness Finally, We then put our costs and effects together AND included the costs of antiretroviral treatment that were saved as a result of the HIV infections averted due to the VMMCs performed. We found that in fact VMMC leads to high long-term savings. These savings occur across both arms and in both regions, but these savings are greater in the intervention arm than in the control arm. The savings are also greater in Njombe than in Tabora.

VMMC subject to economies of scale Conclusions Increased uptake of VMMC by all age groups led to lower unit costs and more HIV infections averted VMMC subject to economies of scale Greater long-term savings in intervention arms (including ART cost savings) There are some limitations to our study. -We cannot disentangle the costs or effects of the different tailored demand creation activities. -The model we used to calculate infections averted were is not a dynamic model so we may be under-estimating our cost-effectiveness. -We also, as of yet, have not included patient costs as part of our analysis. This is particularly important given that VMMC leads to a brief period of physical incapacity. To conclude, we can say that despite the added costs of a tailored demand creation intervention, costs per male circumcised were lower in the intervention arms, which points to economies of scale. We can also say that once you take into account ART savings from infections averted, costs were savedacross the board, but the tailored demand creation approach was less costly and more effective due to increased uptake of VMMC across all age categories. There are stronger regional effects in Njombe and this is likely due to its higher HIV incidence. -

Thank you! Finally a big thank you to our funder, CDC, to our research partners and to Project Soar, PEPFAR and USAID for allowing us to use the DMPPT 2.1 model. Thank IAS for giving us a chance to present our results and to all of you here today for having come to listen to this session. If you have any further questions after today, my email is at the bottom of the slide. Thank you. For further information, please email: Sergio.TorresRueda@lshtm.ac.uk